ine well">
    <fieldset>
        <legend>Registro de paciente</legend>
        
        <table>
            <tr>
                <td>
                    <div class="controls controls-row">
                        <label class="span2" for="codigo">Código Paciente</label>
                        <input type="text" class="span5" id="codigo" DISABLED>
                    </div>

                    <div class="controls controls-row">
                        <label class="span2" for="apePat">Apellido Paterno</label>
                        <input type="text" class="span5" id="paterno">
                    </div>

                    <div class="controls controls-row">
                        <label class="span2" for="apeMat">Apellido Materno</label>
                        <input type="text" class="span5" id="materno">
                    </div>

                    <div class="controls controls-row">
                        <label class="span2" for="nombres">Nombres</label>
                        <input type="text" class="span5" id="nombres">
                    </div>

                    <div class="controls controls-row">
                        <label class="span2" for="sexo">Sexo</label>
                        <input type="radio" name ="optionsRadios" class="span1" id="male" value="male">F
                        <input type="radio" name ="optionsRadios" class="span1" id="female" value="female">M
                    </div>

                    <div class="control-group">
                        <label class="control-label" for="tipoDoc">Tipo de Documento</label>
                        <a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</a>
                        <select class="input-small" name="tipoDoc" id="tipoDocumento">
                            <option>DNI</option>
                            <option>Libreta militar</option>
                        </select>
                        <a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</a>
                        <label class="control-label" for="tipoDoc">N° de Documento</label>
                        <a>&nbsp;&nbsp;&nbsp;</a>
                        <input type="text" class="input-small" id="n_documento">
                    </div>

                    <div class="controls controls-row">
                        <label class="span2" for="nombres">Dirección</label>
                        <input type="text" class="span5" id="direccion">
                    </div>

                    <div class="controls controls-row">
                        <label class="span2" for="nombres">Teléfono</label>
                        <input type="text" class="span5" id="telefono">
                    </div>


                    <div class="controls controls-row">
                        <label class="span2" for="nombres">Fecha de nacimiento</label>
                    </div>

                    <div class="control-group">
                        <label class="control-label" for="dia">Día</label>
                        <select data-placeholder="[día]"
                                class="chzn-select input-small" name="dia" id="dia">
                            <option>01</option>
                            <option>02</option>
                            <option>03</option>
                        </select>

                        <label class="control-label" for="mes">Mes</label>
                        <select data-placeholder="[mes]"
                                class="chzn-select input-small" name="mes" id="mes">
                            <option>Enero</option>
                            <option>Febrero</option>
                            <option>Marzo</option>
                        </select>

                        <label class="control-label" for="anio">Año</label>
                        <select data-placeholder="[año]"
                                class="chzn-select input-small" name="anio" id="anio">
                            <option>1987</option>
                            <option>1988</option>
                            <option>1989</option>
                            <option>1990</option>
                        </select>
                    </div>

                    <div class="control-group">
                        <label class="control-label" for="telDom">Teléfono domicilio</label>
                        <input type="text" class="input-small" id="tel_dom">
                        <label class="control-label" for="telCell">Teléfono celular</label>
                        <input type="text" class="input-small" id="tel_cell">
                    </div>
                </td>
                <td>
                    <div class="right" position="right">
                        <label class="span2" for="foto">Foto del paciente</label>
                        <div class="controls"><img border=2 src="<?php echo base_url(); ?>media/img/blanco.jpg" class="img-polaroid" width ="120px" ></div>
                        <button type="submit" class="btn">Examinar</button>
                    </div>
                </td>
            </tr>
        </table>
        
        <div class="form-actions">
            <button type="submit" class="btn btn-primary">Guardar</button>
            <button type="reset" class="btn">Cancelar</button>
        </div>        
        
    </fieldset>
</form>